Registration Statement For A Charitable Organization Form - Secretary Of State
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State of South Carolina
Post Office Box 11350
Telephone: (803) 734-1790
Office of the Secretary of State
Columbia, SC 29211
Fax: (803) 734-1604
Division of Public Charities
charities@sos.sc.gov
REGISTRATION STATEMENT FOR A CHARITABLE ORGANIZATION
Please type or print clearly.
Filing Fee - $50.00
Check one:
[ ] Initial Registration
[ ] Renewal/Update
Enter Federal Employer’s Identification Number: __ __ - __ __ __ __ __ __ __
Charity Public ID: __________________
Legal Name of Organization _______________________________________________________________________
Doing Business As (DBA) Names ___________________________________________________________________
Former Names used by the Charity ____________________________________________________________________
Organization’s Website ___________________________________________________________________________
Demographic Details
Current Fiscal Year End Date (month/day/year) _______________________
Purpose for which this organization was formed:
_______________________________________________________
_____________________________________________________________________________________________
Enter the state and country in which the organization was legally established, as well as the date of establishment
___________________________________________________________________________________________________
Form of organization. Check one: [ ] Corporation [ ] Association [ ] Trust [ ] LLC
Tax exempt status under the Internal Revenue Code:
[ ] YES [ ] NO
If "Yes," please provide copy of IRS tax exempt documentation.
Is your organization currently, or has it in the past, been the subject of a legal or administrative action concerning a
charitable solicitation, fundraising campaign, or campaign with a commercial co-venturer by another local, state or federal
governmental authority including, but not limited to, registration or license revocation or denial, fines, injunctions or
suspensions? [ ]YES [ ]NO
If “Yes”, please attach an explanation of all actions.
Have any of the organization’s officers, directors, trustees or board members been the subject of a criminal conviction,
including guilty or nolo contendere pleas, involving any charitable solicitations act, fraud, dishonesty, or false statement in a
jursidiction within the United States? [ ] YES [ ] NO
If “Yes,” please attach a description and date of any such
conviction.
If any of the charitable organization’s officers, directors, trustees or board members are related to one another by blood,
marriage or adoption, please note in the following space.
___________________________________________________________________________________________________
If any of the charitable organization’s officers, directors, trustees or board members are related by blood, marriage or
adoption to a director or officer of a professional fundraising counsel or professional solicitor under contract with the
charitable organization, please note in the following
space.______________________________________________________________________________________________
Registered Agent for Service of Process (Include Name and Address [street address only] of the Registered Agent’s Office)
__________________________________________________________________________________________________
___________________________________________________________________________________________________
_
Charities Registration Statement Revised May 2009
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